Should PLEX Be Used for Severe AKI and/or Pulmonary Hemorrhage in ANCA-Associated Vasculitis (AAV)? COMMENTARY.

Abstract

“To plasmapherese (PLEX) or not to PLEX” is a question in the induction therapy for patients with ANCA-associated vasculitis (1). Drs. Glassock and Derebail present differing yet sometimes overlapping conclusions to this question in their virtual debate. Their erudite analysis carefully examines the available literature from their respective pro or con positions. To focus the issues, let us consider three real-life patients who illustrate the quandary of when, or whether, PLEX should be used. A 32-year-old mother of three is coughing up blood in the emergency room, complaining of worsening fatigue over the past 3 weeks. Physical examination 7 months prior was unremarkable; hemoglobin was 12.8 mg/dl, and serum creatinine was 0.7 mg/dl. Urinalysis was not performed. She describes new, dark, “tea-colored” urine over the past 2 days. Urinalysis shows numerous red blood cells and red cell casts. Kidney biopsy reveals pauci-immune necrotizing and crescentic glomerulonephritis (GN) with necrosis and crescents in three of seven glomeruli. There is minimal or no interstitial infiltrate, fibrosis, or tubular atrophy. Myeloperoxidase (MPO) ANCA is positive at a titer of 93 (normal <20). High-resolution chest computed tomography reveals diffuse alveolar infiltrates with minimal bronchial abnormalities involving multiple lung lobes. Oxygen saturation is 88% on 2 L of oxygen. The diagnosis is MPO ANCA with diffuse alveolar hemorrhage and necrotizing and crescentic GN. In addition to glucocorticoids and intravenous cyclophosphamide/rituximab, would you order plasmapheresis? Dr. Derebail would argue that this patient should receive plasmapheresis. Dr. Glassock specifies that no randomized, controlled trials of PLEX as therapy for diffuse alveolar hemorrhage are available and concludes that “PEXIVAS is not very informative regarding the utility of PLEX …